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Why Quantifiable Information Matters in Defensible Documentation

presented by Maureen McCarthy, BS, RN, RAC-MT, QCP-MT, DNS-MT, RAC-MTA and Ellen R. Strunk, PT, MS, GCS, ACEEAA, CHC, RAC-CT

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Disclosure Statement:

Financial: Ellen R. Strunk and Maureen McCarthy receive compensation from MedBridge for this course. There is no financial interest beyond the production of this course.

Nonfinancial: Ellen R. Strunk and Maureen McCarthy have no competing nonfinancial interests or relationships with regard to the content presented in this course.

Satisfactory completion requirements: All disciplines must complete learning assessments to be awarded credit, no minimum score required unless otherwise specified within the course.

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Video Runtime: 42 Minutes; Learning Assessment Time: 20 Minutes

The implementation of the Patient-Driven Payment Model (PDPM) presents a new landscape for SNF documentation requirements. Clinicians have a lot to learn about what is expected by payers and reviewers alike. Defensible documentation doesn't always mean more documentation. It means documenting more effectively. This course will discuss key components of documentation for the entry- and intermediate-level nurse and therapist, including key components of a comprehensive assessment, the importance of gathering objective information initially and throughout the episode of care, and the impact of the Minimum Data Set.

Meet Your Instructors

Maureen McCarthy, BS, RN, RAC-MT, QCP-MT, DNS-MT, RAC-MTA

Maureen is the president of Celtic Consulting, LLC, a clinical reimbursement, clinical operations, and compliance advisory firm. She is also the CEO of MDSRescue, an organization that provides temporary MDS completion services across the country. Recognized as an industry leader in clinical reimbursement for long-term care, Maureen has been a registered nurse for more than…

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Ellen R. Strunk, PT, MS, GCS, ACEEAA, CHC, RAC-CT

Ellen R. Strunk has worked in various roles and settings as a clinician, manager/director, and policy expert. Ellen is an expert at helping customers understand the Centers for Medicare & Medicaid Services (CMS) prospective payment systems in the skilled nursing facility and home health settings, as well as outpatient therapy billing for all provider types.…

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Chapters & Learning Objectives

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1. Principles of a Comprehensive Assessment

This chapter will present the key components of a nursing assessment and a therapy assessment. The concepts of skilled, reasonable, and necessary will be articulated in terms nurses and therapists will understand. The importance of creating a clearly defined plan of care with interprofessional goals and strategies is critical to ensuring documentation is defensible to anyone reviewing it.

2. Capturing Objective Information

Collecting key pieces of objective information is an important task for nurses and therapists alike. The information collected helps to put the pieces of the resident’s care plan into place and supports the medical necessity of the interventions. Payers expect to see measures that are standardized and have some predictive or other clinical value. This chapter will share examples of objective tools and assessments and how to integrate them into the documentation.

3. The Role of the Minimum Data Set

The Minimum Data Set (MDS) is the foundation of the resident assessment process in a skilled nursing facility. This chapter will explain the fundamental parts of the MDS, its role in reflecting patient care, and its connection to payment.

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